Chain of custody record for Westchester County Department

NYC 9/11 Public Portal Document

ENVIRONMENTAL SERVICES SAMPLE SUBMISSION FORM ister WESTCHESTER COUNTY LABORATORIES AND RESEARCH Dvcom 2 Dana Road, Valhalla, New York 10595 (914)231-1620 Fax (914) 231-1772 NYS-ELAP No. 10108 ' Time/Date Set: Form A-70 (rev. 10/01)

Sample Type (circle one): 2--/.7 i.PpJay^ 3. Non Potable Treated Bottle #’s: 2. Non Potable 4. Other____________ Chain of Custody?___ Yes No Time/Date Collected:• / Comments: j_____________ Collected By:. ~ Agency Code: PWS#:.______ Source ID:. Type' Descriptor: ' ■ /j.. t&v i ■ I Collected From: Bill to: 1 Location’s/lndividuars Name Name/Conipiany Street_________________ Street _ ______ City/St/Zip:______________ City/St/Zip Identification of Source Phonei#: Collection Point ----- ------------------------ I CA,CH, Bl?

BACTERIOLOGICAL ANALYSIS Lab#:_______________________ ORGANIC POTABLE analysis / .■ ; __ Heterotrophic Plate Count _Tn'halomethanes (524) _i Futgeabl^HS6rafB6n^t62^^)W^<?^ (hemodialysis & all others) _ Volatile Halocarbons (524) _ Purgeable' Aromatics^(624/8260j '7V < < __ Coliform P/A (Public supplies) __ Coliform MPN (priv well, raw, stp) _ Volatile Aromatics (524) ■ _ Acroleih&;Acrylonitnlel(8260)7 __ Fecal Coliform (all samples) __ Total Trihalomethane Potential (510) _ Organochldrihe Pesticides ?(608/8081) 7- ; __ Microscopic __ Microextractables (504) , . -. , / PCBr(Ar8aflo^)t(668«O8i^^^ __ Macroscopic __ Pesticides/PCB screen (508) . Herbicid^Wi8/fe63b:8l51) «^<:;r<. V < _ API __ PCB as Decachlorobiphenyl (508A) Other Pe^ici^^(^8/66^)>Y<< Y< __ Other:_____________________ _ Herbicides (515) __ .Petroleum I4yclrfe'ffi6n^ (310-13) 7/W __ Pesticides (525) .■_i_ Glycols in,VVatPr^7'i-:’'Yi''' • 'X/: Refrigerated?yes___ no __ Carbamate Pesticides (531) _ Acid Extractables (625/8270) . Y l : , Chlorinated:?yes___ no __ Glyphosate (547) _ Base Neutral Extractables (625/8270) Diquat (549) Jr^C/MS Unknown Scan " ' '■ Free Chlorine Res:mg/L __ Chlorination Disinfection Byproducts (551) _ Phthalates (606MS) . , Y' , . I Total Chlorine Res:mg/L __ Haloacetic Acids (552) __ Other Pesticides (SMI8/6630) pH ___________ _UCMR List 1 RADIOCHEMICAL ANALYSIS _ MtBE Only (524) __ Radon __ Other____________________

INORGANIC ANALYSIS REQUESTED - Lab#: __ Color __ /Acidity 21. Aluminum _ Potassium __ Turbidity _ Alkalinity Antimony .^'Selenium _ pH __ Bromide .^Arsenic j^i^ilyerJ '__ Conductivity __ Bromate/Chlorate/Chlorite _u:-Barium ___ Sodium . __ Corrosivity (temp:. .’C) __ Chloride jx^eryllium W- _ BOD (5 day) __ Cyanide __ Boron __ ; VanaSium^/ / /' __ Carbonaceous BOD (5 day) __ Fluoride __ Cadmium _ Soluble BOD (5 day) __ Hardness, Total as CaCOa __ Calcium, as CaCOs __ Chemical Oxygen Demand __ Nitrogen, Ammonia as N __ Calcium, Ca*^ __ Dissolved Oxygen ■_'Metpls/CN __ Nitrogen, Nitrate as N JsrChromium, Total __ Total Organic Carbon _ : Volatiles _ _ Nitrogen, Nitrite as N __ Chromium, Hexavalent ■ Serhi-vlolatiles __ Total Organic Halides __ Nitrogen, Total Kjeldahl as N AxCobalt _ Pesticides/PCB’s __ Solids, Percent (%) __ Oil and Grease v^Copper __ Solids, Settleable __ Phenol Iron __ Solids, Suspended __ Phosphorus Total as P '..-Lead ICLE _TCLP-Metals __ Solids, Total __ Phosphorus, Ortho as P __ Magnesium _LTCLP-Pesticides __ Solids, Total Dissolved ’ ' ■' _1 Sulfates 1:2 Manganese _TCLP-Herbicides __ Solids, Total Volatile __ Surfactants .'Mercury u^-tviercury • TCLP-VqIatiles " __ Other: _ UV254

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